Stress Effects on Pharyngeal Air Pressure and Upper Esophageal Sphincter Pressure During Phonation: The Influence of Vocal Tract Semi-Occlusion



      The objective of this study was to determine whether vocal tract semi-occlusion (SOVT) influenced stress effects on pharyngeal air pressure and upper esophageal sphincter (UES) pressure during phonation. Relationships between dysphonia and stress are well recognized but poorly understood. Stress effects act globally on the body, and may be observed beyond intrinsic laryngeal muscles to include pharyngeal muscles and the UES, which contribute to voice modulation. Phonation with SOVT may provide resistance to stress effects on the vocal tract. We hypothesized that stress effects on pharyngeal air pressure and UES pressure would be measurable with a high-resolution, 360° pressure catheter, and that stress effects would be impacted differently by occlusal and non-occlusal phonatory tasks.


      Ten healthy adults performed sustained vowel tasks (comfortable /a/, and loud /a/), and SOVT tasks (bilabial fricative and straw phonation). Each task was performed during a baseline condition, and during stress induced through a cold pressor task. Pharyngeal air pressure and UES pressure were measured via high-resolution manometry. Changes in pressure between baseline and stress were compared among phonatory tasks.


      Stress-induced changes to UES pressure differed by phonatory task (P < 0.01). Stress increased UES pressures during vowels, but had no effect during bilabial fricative, and decreased UES pressures during straw phonation. Change in UES pressure with stress was greater for comfortable /a/ and loud /a/ than straw phonation (P = 0.048 and P = 0.019, respectively), and was not significantly different between comfortable /a/ or loud /a/ and bilabial fricative. Stress-induced changes in pharyngeal air pressure were not significantly different among tasks.


      These findings help identify possible mechanisms underlying the relationship between stress and voice, and point to the utility of SOVT tasks for training vocal tract resistance to stress. This methodology provides a foundation for measuring changes to extra-laryngeal components of the vocal tract during phonation.

      Key Words


      SOVT (Semi-occluded vocal tract), UES (Upper esophageal sphincter), HRM (High-resolution manometry), F0 (Fundamental frequency)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Voice
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Roy N
        • Bless DM
        • Heisey D.
        Personality and voice disorders: a superfactor trait analysis.
        J Speech Lang Hear Res. 2000; 43: 749-768
        • Roy N
        • Bless DM
        • Heisey D.
        Personality and voice disorders: A multitrait-multidisorder analysis.
        J Voice. 2000; 14: 521-548
        • Misono S
        • Meredith L
        • Peterson CB
        • et al.
        New perspective on psychosocial distress in patients with dysphonia: the moderating role of perceived control.
        J Voice. 2016; 30: 172-176
        • Marmor S
        • Horvath KJ
        • Lim KO
        • et al.
        Voice problems and depression among adults in the United States.
        Laryngoscope. 2016; 126: 1859-1864
        • Nguyen-Feng VN
        • Frazier PA
        • Stockness A
        • et al.
        Assessing change over time in voice handicap and voice-related perceived control using ecological momentary assessment.
        Ann Otol Rhinol Laryngol. 2019; 128: 829-837
        • Perrine BL
        • Scherer RC.
        Aerodynamic and acoustic voice measures before and after an acute public speaking stressor.
        J Speech Lang Hear Res. 2020; 63: 3311-3325
        • Pisanski K
        • Nowak J
        • Sorokowski P.
        Individual differences in cortisol stress response predict increases in voice pitch during exam stress.
        Physiol Behav. 2016; 163: 234-238
        • Helou LB
        • Rosen CA
        • Wang W
        • et al.
        Intrinsic laryngeal muscle response to a public speech preparation stressor.
        J Speech Lang Hear Res. 2018; 61: 1525-1543
        • Dietrich M
        • Andreatta RD
        • Jiang Y
        • et al.
        Limbic and cortical control of phonation for speech in response to a public speech preparation stressor.
        Brain Imaging Behav. 2019; (Online Ahe)
        • Macpherson MK
        • Abur D
        • Stepp CE.
        Acoustic measures of voice and physiologic measures of autonomic arousal during speech as a function of cognitive load.
        J Voice. 2017; 31: 504.e1-504.e9
        • Dietrich M
        • Verdolini Abbot K.
        Psychobiological stress reactivity and personality in persons with high and low stressor-induced extralaryngeal reactivity.
        J Speech Lang Hear Res. 2014; 57: 2076-2089
        • Abur D
        • MacPherson MK
        • Shembel AC
        • et al.
        Acoustic measures of voice and physiologic measures of autonomic arousal during speech as a function of cognitive load in older adults.
        J Voice. 2021; (Published online)
        • van Mersbergen M
        • Lanza E.
        Modulation of relative fundamental frequency during transient emotional states.
        J Voice. 2018; (Published online)
        • van Mersbergen M
        • Delany M.
        Vocal responses to emotional picture viewing.
        Logop Phoniatr Vocology. 2014; 39: 99-107
        • van Mersbergen M
        • Patrick C
        • Glaze L.
        Functional dysphonia during mental imagery: testing the trait theory.
        J Speech Lang Hear Res. 2008; 51: 1405-1423
        • van Mersbergen M
        • Lyons P
        • Riegler D.
        Vocal Responses in Heighted States of Arousal.
        J Voice. 2015; (Published online)
        • Giddens CL
        • Barron KW
        • Clark KF
        • et al.
        Beta-adrenergic blockade and voice : a double-blind, placebo-controlled trial.
        J Voice. 2010; 24: 477-489
        • Helou LB
        • Wang W
        • Ashmore RC
        • et al.
        Intrinsic laryngeal muscle activity in response to autonomic nervous system activation.
        Laryngoscope. 2013; 123: 2756-2765
        • Nguyen-Feng VN
        • Frazier PA
        • Stockness A
        • et al.
        Web-based perceived present control intervention for voice disorders: a pilot study.
        J Voice. 2018; (Published online)
        • Miller T
        • Deary V
        • Patterson J.
        Improving access to psychological therapies in voice disorders: A cognitive behavioural therapy model.
        Curr Opin Otolaryngol Head Neck Surg. 2014; 22: 201-205
        • Daniilidou P
        • Carding P
        • Wilson J
        • et al.
        Cognitive behavioral therapy for functional dysphonia: A pilot study.
        Ann Otol Rhinol Laryngol. 2007; 116: 717-722
        • Lang IM
        • Shaker R.
        An update on the physiology of the components of the upper esophageal sphincter.
        Dysphagia. 1994; 9: 229-232
        • Vinney LA
        • Connor NP.
        Structure and Function of the Laryngeal and Pharyngeal Muscles.
        in: McLoon L Andrade F Craniofacial Muscles. Springer, 2012: 141-166
        • Zenker W
        • Zenker A.
        Über die Regelung der Stimmlippenspannung durch von außen eingreifende Mechanismen.
        Folia Phoniatr Logop. 1960; 12: 1-36
        • Vilkman E
        • Sonninen A
        • Hurme P
        • Körkkö P.
        External laryngeal frame function in voice production revisited: A review.
        J Voice. 1996; 10: 78-92
        • Sonninen A.
        The external frame function in the control of pitch in the human voice.
        Ann N Y Acad Sci. 1968; 155: 68-90
        • Sonninen A
        • Vilkman E
        • Hurme P.
        Cricopharyngeal muscle in fundamental frequency regulation.
        Logop Phoniatr. 1992; 8: 93-104
        • Perera L
        • Kern M
        • Hofmann C
        • et al.
        Manometric evidence for a phonation-induced UES contractile reflex.
        Am J Physiol - Gastrointest Liver Physiol. 2008; 294: 885-891
        • Cook IJ
        • Dent J
        • Shannon S
        • Collins SM.
        Measurement of upper esophageal sphincter pressure. Effect of acute emotional stress.
        Gastroenterology. 1987; 93: 526-532
        • Cook IJ
        • Dent J
        • Collins SM.
        Upper esophageal sphincter tone and reactivity to stress in patients with a history of globus sensation.
        Dig Dis Sci. 1989; 34: 672-676
        • Ayres RCS
        • Robertson DAF
        • Naylor K
        • et al.
        Stress and oesophageal motility in normal subjects and patients with irritable bowel syndrome.
        Gut. 1989; 30: 1540-1543
        • Titze IR.
        Voice training and therapy with a semi-occluded vocal tract: rationale and scientific underpinnings.
        J Speech Lang Hear Res. 2006; 49: 448-459
        • Hoffmeister JD
        • Ulmschneider CL
        • Jones CA
        • et al.
        Measurement of pharyngeal air pressure during phonation using high-resolution manometry.
        J Speech Lang Hear Res. 2021; (Published online July 28): 1-9
        • Vaiano T
        • Herbella FAM
        • Behlau M.
        Pharyngeal, upper esophageal sphincteric and esophageal pressures responses related to vocal tasks at the light of high resolution manometry.
        Arq Gastroenterol. 2021; 58: 296-301
        • Lovallo W.
        The cold pressor test and autonomic function- a review and integration.
        Psychophysiology. 1975; 12: 268-282
        • Eisen AR
        • Rapee RM
        • Barlow DH.
        The effects of breathing rate and pCO2 levels on relaxation and anxiety in a non-clinical population.
        J Anxiety Disord. 1990; 4: 183-190
        • Sonninen A
        • Laukkanen AM
        • Karma K
        • et al.
        Evaluation of support in singing.
        J Voice. 2005; 19: 223-237
        • Titze IR
        • Palaparthi A
        • Cox K
        • et al.
        Vocalization with semi-occluded airways is favorable for optimizing sound production.
        PLoS Comput Biol. 2021; 17: 1-21
        • Clark ME
        • Hirschman R.
        Effects of paced respiration on anxiety reduction in a clinical population.
        Biofeedback Self Regul. 1990; 15: 273-284
        • Lang IM
        • Dantas R
        • Cook I
        • et al.
        Videoradiographic, manometric, and electromyographic analysis of canine upper esophageal sphincter.
        Am J Physiol - Gastrointest Liver Physiol. 1991; 260: G911-G919
        • Roy N
        • Ford CN
        • Bless DM.
        Muscle tension dysphonia and spasmodic dysphonia: The role of manual laryngeal tension reduction in diagnosis and management.
        Ann Otol Rhinol Laryngol. 1996; 105: 851-856
        • Khoddami SM
        • Ansari NN
        • Jalaie S.
        Review on laryngeal palpation methods in muscle tension dysphonia: validity and reliability issues.
        J Voice. 2015; 29: 459-468
        • Angsuwarangsee T
        • Morrison M.
        Extrinsic muscular tension in patients with voice disorders.
        J Voice. 2002; 16: 333-343
        • Giddens CL
        • Barron KW
        • Byrd-Craven J
        • et al.
        Vocal indices of stress: A review.
        J Voice. 2013; 27: 390.e21-390.e29
        • Van Lierde K
        • Van Heule S
        • De Ley S
        • Mertens E
        • Claeys S.
        Effect of psychological stress on female vocal quality.
        Folia Phoniatr Logop. 2009; 61: 105-111
        • Roy N
        • Bless DM
        • Heisey D
        • et al.
        Manual circumlaryngeal therapy for functional dysphonia: An evaluation of short- and long-term treatment outcomes.
        J Voice. 1997; 11: 321-331
        • Winiker K
        • Gozdzikowska K
        • Guiu Hernandez E
        • et al.
        Potential for volitional control of resting pressure at the upper oesophageal sphincter in healthy individuals.
        Dysphagia. 2021; 36: 374-383
        • Patel RR
        • Awan SN
        • Barkmeier-kraemer J
        • et al.
        Recommended protocols for instrumental assessment of voice: american speech- language-hearing association expert panel to develop a protocol for instrumental assessment of vocal function.
        Am J Speech Lang Pathol. 2018; 27: 887-905
        • Goodman WK
        • Janson J
        • Wolf JM.
        Meta-analytical assessment of the effects of protocol variations on cortisol responses to the Trier Social Stress Test.
        Psychoneuroendocrinology. 2017; 80: 26-35
        • McRae AL
        • Saladin ME
        • Brady KT
        • et al.
        Stress reactivity: Biological and subjective responses to the cold pressor and Trier Social stressors.
        Hum Psychopharmacol. 2006; 21: 377-385
        • Schwabe L
        • Haddad L
        • Schachinger H.
        HPA axis activation by a socially evaluated cold-pressor test.
        Psychoneuroendocrinology. 2008; 33: 890-895
        • Kudielka BM
        • Hellhammer DH
        • Wüst S.
        Why do we respond so differently? Reviewing determinants of human salivary cortisol responses to challenge.
        Psychoneuroendocrinology. 2009; 34: 2-18